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Myelomeningoceles (open spina bifida) -Fetoscopic Intrauterine Myelomeningocele Closure
With Lurie Children's Hospital
Chapter 1 of 6 · Fundamentals
Myelomeningocele background
Introduction and Background on Myelomeningocele
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Under ultrasonic guidance, 4 full thickness sutures are placed through the uterine wall to delineate a 1 centimeter square area through which a 10 French trochar is inserted using Seldinger technique.
After removing a portion of the amniotic fluid, the uterus is insufflated with warm, humidified carbon dioxide.
Dissection of the myelomeningocele begins lateral to the exposed spinal cord, detaching it from the arachnoid and skin.
The spinal cord is circumferentially released, taking care not to injure the ascending spinal cord, lateral dorsal roots, or segmental vasculature.
The dura attaches laterally and ventrally to the open skin edge at the junctional zone.
The lateral extent of the dura is identified and detached.
A running, non-absorbable 6-0 suture is utilized to re-approximate the delicate dura, which will persist long term and act as a useful guide if subsequent untethering is required.
In some cases, the size of the skin defect may prevent primary skin closure.
A synthetic skin graft may be utilized and sutured to the edges of the healthy skin when primary closure is not possible.
The synthetic skin graft will promote eventual epithelialization of the open defect.
Myelomeningocele or open spina bifida is a neural tube defect.
Myelomeningocele is when the spinal cord does not close and is exposed on surface through an opening in the spine.
Myelomeningocele usually occurs in the low back region.
The incidence of neural tube defects is around 0.2 per 1000 live births in the United States.
When diagnosed prenatally, neural tube defects can be repaired during the fetal stage of life while in utero.
The pregnant patient is placed under general anesthesia and the uterus is approached by a midline laparotomy.
An ultrasound is used to map the location of the placenta and major vessels on the uterine surface.
Two subsequent trochars are placed under endoscopic visualization.
Prior to surgical intervention, the fetus is administered a sedative cocktail of rocuronium, fentanyl, and atropine.
The surgeon uses tenotomy scissors and right-angled hook electrocautery to sharply dissect through the tissue, which completely frees the placode.
The neural placode is reconstructed with interrupted 6-0 sutures after it is completely untethered from the skin.
The dural closure area can be an area of great tension.
Lateral fascia and muscle may be freed to allow medialization and primary closure of the dura under less tension.
Skin closure should be performed in the mid-sagittal plane when possible.
Skin closure may require mobilization of the skin, including subcutaneous fat layer, as the skin's vascular supply comes through this layer.
Blunt dissection in the plane between the muscle and subcutaneous fat is the best method to preserve the blood supply.
After completing the fetal back closure, the amniotic fluid is replaced in the uterus with warmed, lactated Ringer solution.
The ports are removed and the insertion sites are closed, the uterus is returned to the abdominal cavity and the abdominal incision is closed in the standard fashion.